This presentation looks at some of the common conditions that can present with hemiplegia. Stroke is the commonest, however, there are several other causes that need to be considered in a patient presenting with hemiplegia.

1. APPROACH TO
HEMIPLEGIA
DR SUDHIR KUMAR MD DM (NEUROLOGY)
SENIOR CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, HYDERABAD

2. OVERVIEW
• Brain stroke is the commonest cause of hemiplegia,
• Stroke is among the three most common causes of death
and disability (heart attack and cancer are the other two),
• It is important to correctly and quickly diagnose stroke, as
treatment (thrombolysis) is time-bound,
• Missed or delayed diagnosis can deny thrombolytic
therapy,
• On the other hand, thrombolysis of a “stroke-mimic” may
be harmful
• We look at some of the common stroke mimics, which
can present with acute onset hemiplegia

3. CASE 1
• 60-year old man,
• One hour duration of drowsiness, headache and
vomiting,
• BP: 220/110 mmHg
• Left-sided weakness

4. CT BRAIN

5. DIAGNOSIS
• Brain hemorrhage
• Contraindication to thrombolysis,
• About one-third of all strokes,
• Management includes control of BP and lowering of
ICP (mannitol, mechanical ventilation); surgery in
some cases.

6. CASE 2
• 55-year old lady,
• Known diabetic,
• Right hemiplegia of 45 minutes duration
• On admission, power grade 0/5 in right UL, LL
• CT brain- normal
• 30 min later, complete recovery. Power-grade 5/5 all
4 limbs

7. DIAGNOSIS
• TIA- transient ischemic attack
• No need to thrombolyse in cases of TIA
• However, if the recovery is incomplete, thrombolysis
should be considered
• All patients with TIA should be started on anti-
platelets and statins, as they have a high risk of
stroke in future, esp in the first 30 days after TIA.

8. CASE 3
• 70-year old man,
• Sudden onset left hemiplegia of two hours duration,
• History of fall at home present,
• Mild drowsiness, power grade 3/5 left UL, LL

9. CT BRAIN

10. DIAGNOSIS
• Acute subdural hematoma (SDH)
• Treatment is urgent surgery- Burr hole evacuation of
hematoma.

11. CASE 4
• 25-year old lady,
• Acute onset weakness of right side of body of three
hours duration,
• Preceded by headache for three days,
• One episode of seizure while in ER,
• Drowsy, arousable, obeys a few commands
• Power grade 3/5 right UL, LL

12. CT BRAIN

13. DIAGNOSIS
• CVST (Cerebral venous sinus thrombosis)
• Common in post-partum period, after OCP use,
head injury, thrombogenic states such as nephrotic
syndrome, malignancy, protein C/S deficiency
• Confirm by MRI/MRV brain
• Treatment- anticoagulation with heparin
• Intra-sinus thrombolysis in selected cases.

14. CASE 5
• 21-year old man presented with weakness of right
arm and leg of three hours duration,
• He had a GTCS at the onset of weakness,
• He had history of epilepsy in childhood, and was
treated with valproate for three years.
• Conscious, alert, power grade 3/5 in right UL, LL

15. CT BRAIN
• CT brain- normal
• Diagnosis- Todd’s paresis
• Todd’s paralysis can last from 30 min to 36 hours
(average duration is 15 hours)
• Resolves on own and no treatment is necessary.

16. CASE 6
• 55-year old lady,
• Known diabetic on metformin and glimepiride,
• Brought to ER with sudden onset left hemiplegia and
drowsiness of one hour duration
• Drowsy, not obeying commands, left hemiplegia,
• CT brain- normal

17. • RBS- 30 mg%
• Diagnosis- hypoglycemic hemiparesis
• Hemiparesis occurs in 4.2% cases of hypoglycemia,
at an average glucose of 32 mg% or less,
• Mostly right hemiparesis (in 66% of cases)
• Internal capsule or splenium of corpus callosum
lesion may be seen on MRI brain,
• Rapidly improves with dextrose infusion

18. CASE 7
• 19-year old girl
• Presented with acute onset right hemiplegia and
aphasia of two hours duration,
• History of fever and cough two weeks ago, subsided
in 3 days on own

19. MRI Brain

20. DIAGNOSIS
• Acute disseminated encephalo-myelitis (ADEM)
• An auto-immune condition, affecting white matter of
brain,
• Treated with IV methylprednisolone for 3-5 days
• Good recovery is seen.

21. OTHER CAUSES of
hemiplegia
• Hyperglycemia,
• Hyponatremia,
• Brain tumor with bleed,
• Brain abscess,
• Encephalitis, meningitis

22. COMMENTS/QUERIES
Whatsapp: 9866193953
Email: drsudhirkumar@yahoo.com
Facebook: www.facebook.com/bestneurologist/